Transcript Adult ADHD

Workshop on ADHD in Third
Level students
Fiona McNicholas
Martin O’Sullivan
Consultant Lucena Clinic, Rathgar
& Our Lady’s Hospital for Sick
Children, Crumlin
Professor Child & Adolescent
Psychiatry, UCD
Consultant Child and Adolescent
Psychiatrist
Mater Hospital and St Vincent’s
Hospital Fairview
26 Jan 2006
Overview of Talk
• ADHD in children
• ADHD in adults
• Treatment of ADHD
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ADHD- as we know it!
Inattention
Hyperactivity
Impulsivity
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Diagnostic criteria
(ICD/DSM)
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Over activity
Inattention
Impulsivity
Symptoms before age 7
(6 ICD)
• Pervasive across
situation
• Cause impairment of
social or educational
functioning.
• Not due to PDD,
Psychotic or other mental
disorder (anxiety,
depression)
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Inattention: (6/9)
– Fails to give close attention to details or makes careless errors in
schoolwork, or other activities
– Difficulty sustaining attention in tasks or play activities
– Does not seem to listen when spoken to directly
– Does not follow through on instructions and fails to finish school
work, chores or duties (not due to oppositional behaviour or
failure to understand)
– Difficulty organising tasks/activities
– Avoids, dislikes or reluctant to engage in tasks that require
sustained mental effort
– Loses things necessary for tasks
– Easily distracted by extraneous stimuli
– Forgetful in daily activities
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Hyperactivity/Impulsivity (6/9)
• Fidgets with hands or feet or squirms in
chair
• Leaves seat in classroom or other in
which sitting is expected
• Runs about, climbs excessively in
situations in which it is inappropriate
(restless)
• Difficulty playing in activities quietly
• ‘On the go’ or ‘driven by a motor’
• Talks excessively
• Blurts out answers
• Difficulty awaiting turn
• Interrupts or intrudes on others
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Common Associated
Comorbidities
60
40
(%)
20
0
Oppositional Anxiety Learning
defiant
disorder disorder
disorder
Mood Conduct
disorder disorder
Milberger et al. Am J Psychiatry 1995; 152: 1793–1799
Biederman et al. J Am Acad Child Adolesc Psychiatry 1997; 36: 21–29
Castellanos. Arch Gen Psychiatry 1999; 56: 337–338
Goldman et al. JAMA 1998; 279: 1100–1107
Szatmari et al. J Child Psychol Psychiatry 1989; 30: 219–230
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Substance
use disorder
Tics
Prevalence
• ICD 1-2 % or DSM IV 3-5%
• 30-50% of children referred to child psychiatry clinics have ADHD
• Diagnosed in boys 3-4 often than in girls
• Persists in 30-50% of patients into adolescence and adulthood
(symptom profile may change)
• Prevalence in Adults: 2%
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Associated problems
• School:
• Language impairment 1575%
• Learning Disability 1540%
• Low Self esteem
• Poor social skills
• Labelled
‘trouble maker’
• Poor relationship with
parents
– often secondary and
improves with
appropriate
intervention
• Family History ADHD
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ADHD more likely than norms to
• Drop out of school 32-40%
• Experience teen pregnancy
40%
• Rarely complete college 510%
• Sexually transmitted disease
16%
• Under-perform at work 70-80%
• Have few or no friends 50-70%
• Engage in antisocial activities
40-50%
• Speed or have car accidents
• Suffer from depression 20-30%
• Have a personality disorder
18-25%
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Assessment: History & Observations
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Symptoms of ADHD
– Home
– School
– After school activities
Co-morbidity
– LD
– Motor
– ODD/CD
– Other child psychiatric
disorders
• Informants
– Parents
– Child
– Teacher, Coach, play
school, clubs etc
• Tests
– Physical examination
Rating scales
– Formal assessments
NEPS, SALT, OT, hearing,
vision
Perpetuating factors
– Family
– Temperament
– Environment
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ADHD in Adults?
• ADHD child grown up
• Parent of newly diagnosed ADHD child
• Adult recognizing symptoms of ADHD for
the first time
• New onset ADHD symptoms-’secondary
ADHD’
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Issues re Adult ADHD
• DSM IV diagnosis valid for children
• ? Natural History
• Assessment process
– Retrospective recall
– Multi rater
– Inappropriate wording -new scales
• Self referral versus childhood continuation
• Developmental disorder PDD or Psychiatric
disorder such as Depression
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Diagnosis of Adult ADHD
• Criteria:
• Assessment:
– Childhood criteria
meet
– Current symptoms
– Impairment
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Clinical interview
Collateral
Childhood records
Rating Sclaes
The UTAH Criteria for adult ADHD
• DDx: schizophrenia,
borderline PD or SUD
• Childhood history
• Adult symptoms of
– Motor hyperactivity
– Attention deficits
• Associated features
• Plus two of the following:
– Affective lability
– Hot tempers, explosive and
short lived outbursts
– Emotional over reactivity
– Disorganisation, inability to
complete tasks
– Impulsivity
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– Marital instability
– Sub-optimal academic and
vocational success,
– Alcohol or drug misuse,
– Family history of ADHD,
– Antisocial personality
disorder
– Atypical response to
psychoactive medications.
Adult ADHD Rating Scales
• Conner’s 4 dimensions
– Cognitive Dysfunction
• Inattention, disorganization, procrastination, poor
memory, poor time management
– Hyperactivity
• Predominantly inner restlessness, impatience
– Emotional Impulsivity
• Rages, tempers, anger management issues, mood
lability, frustration
– Self Esteem & Self worth
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Adult Rating Scales
• Brown Adult & Adolescent rating Scale
– Self report and significant other
• ADHD Rating Scale
– Developed by Adler et al, Boston group
– DSM IV items reworded for adults
• How often have you had difficulty in wrapping
up the final details of a project once the
challenging parts have been done?
• ASRS-V1.1 www.adultadd.com
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Adult Self Report Scale (WHO)
• How often do you have trouble wrapping up the final details of a
project, once the challenging parts have been done?
• How often do you have difficulty getting things in order when you
have to do a task that requires organization?
• How often do you have problems remembering appointments or
obligations?
• When you have a task that requires a lot of thought, how often do
you avoid or delay getting started?
• How often do you fidget or squirm with your hands or your feet
when you have to sit down for a long time?
• How often do you feel overly active and compelled to do things,
like you were driven by a motor?
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Differences between Adult and
Child cases ADHD
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Male: female ratio 3:2 vs 3:1 – 10:1
Source of referral
Motivation for treatment
Who is affected by ADHD?
Insight/ awareness
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Functional Impairment
• Weiss Functional Impairment Rating Scale (v2
2005)
- Margaret D Weiss [email protected]
Domains:
Family
Work / School / College
Life Skills
Self – Concept
Social
Risk
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WFIRS-S
• Provides information on breadth and
severity of impairment
• Can be used to track changes over time
• Psychometric properties of the scale
currently under investigation
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Brown Attention Deficit Disorder
Scale
5 important symptom clusters
• Getting organised, activating tasks
• Sustaining focus, especially reading
• Alertness, effort, processing speed,
motivation
• Affect
• Working memory, memory retrieval
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Clinical Vignette 1
Walter, 26
• Very superior IQ
• Wide variation in College scores, some
papers brilliant, others failed
• Previous history of Dx ADHD + use of
Ritalin – stopped aged 14
• Drops out of College year 3 – many short
papers, projects not completed
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Clinical Vignette 2
Maria, 24
• Primary school teacher trainee
• “Terrible planning, organising”
• Procrastinates, late with assignments
• Can’t keep up with the reading
• Finances in a mess – maxed out on Credit
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Clinical Vignette 3
Anthony, 26
• 3rd attempt at third-level degree
• Makes good starts then gets bored
• Conflict with supervisors
• Regular cannabis use
• Once supportive parents losing patience
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How Medication works: Stimulants
Presynaptic Neuron
Amphetamine
blocks
vv
Storage
vesicle
Cytoplasmic DA
Amphetamine
blocks
reuptake
DA Transporter
Synapse
Methylphenidate
blocks
reuptake
Wilens T, Spencer TJ. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998;501-513.
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Treatment - Psychostimulants
Methylphenidate or Amphetamine
• First line medications for the treatment of
AD/HD in adults off-label
• Clinical response is dose related
>1mg/kg/day
• Efficacy rates ~(25-) 70%
• Successful treatment results in diminished
substance misuse
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Psychostimulants II
Possible side effects
• Insomnia, headaches,anxiety, loss of
appetite
• Cardiovascular:  BP 4mmHg; bpm +10
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Psychostimulants III
• Immediate release MPH require two –
three doses e.g. Ritalin, Equasym
• Extended / sustained release MPH e.g.
Ritalin LA, Concerta
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Psychostimulants IV
• Immediate release Amphetamine
• E.g. Dexedrine, Adderall
• Extended or sustained release:
• E.g. Adderall XR
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Non-stimulant medicationsAtomoxetine HCl
Strattera
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Approved by FDA for treatment of adults
Potent selective NA reuptake inhibitor
Not ‘controlled’
C/I MAOI users, glaucoma
Cautions: liver problems/ cardiovascular/
depression/ suicidality
• Await trials in those with depression/ anxiety
• Metabolised CYP2D6 enzyme Fluoxetine,
Paroxetine and Quinidine inhibit this enzyme
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Non-stimulant medicationsOther
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SSRIs not effective
TCAs – Des., Imip, moderate effect
MAOIs no controlled trials
Bupropion DA NA atypical anti dep
Venlafaxine NA 5HT blocker
Clonidine alpha-2 NA
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Conclusions
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Questions?
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